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STATE-OF-THE-ART PAPER

Smallpox vaccination and myopericarditis: a clinical review

Dimitri C. Cassimatis, MD^*,*, J. Edwin Atwood, MD, FACC^*, Renata M. Engler, MD^*, Peter E. Linz, MD, FACC, John D. Grabenstein, PhD and Marina N. Vernalis, DO, FACC^*

^* Walter Reed Army Medical Center, Washington, DC, USA
Naval Medical Center San Diego, San Diego, California, USA
Military Vaccine Agency, United States Army Medical Command, Falls Church, Virginia, USA

Manuscript received August 11, 2003; revised manuscript received November 5, 2003, accepted November 13, 2003.

^* Reprint requests and correspondence: Dr. Dimitri C. Cassimatis, Walter Reed Army Medical Center, Cardiology, 6900 Georgia Ave., NW, Washington, DC 20307, USA.
dimitri.cassimatis{at}na.amedd.army.mil

Smallpox is a devastating viral illness that was eradicated after an aggressive, widespread vaccination campaign. Routine U.S. childhood vaccinations ended in 1972, and routine military vaccinations ended in 1990. Recently, the threat of bioterrorist use of smallpox has revived the need for vaccination. Over 450,000 U.S. military personnel received the vaccination between December 2002 and June 2003, with rates of non-cardiac complications at or below historical levels. The rate of cardiac complications, however, has been higher than expected, with two confirmed cases and over 50 probable cases of myopericarditis after vaccination reported to the Department of Defense Smallpox Vaccination Program. The practicing physician should use the history and physical, electrocardiogram, and cardiac biomarkers in the initial evaluation of a post-vaccination patient with chest pain. Echocardiogram, cardiac catheterization, magnetic resonance imaging, nuclear imaging, and cardiac biopsy may be of use in further workup. Treatment is with non-steroidal anti-inflammatory agents, four to six weeks of limited exertion, and conventional heart failure treatment as necessary. Immune suppressant therapy with steroids may be uniquely beneficial in myopericarditis related to smallpox vaccination, compared with other types of myopericarditis. If a widespread vaccination program is undertaken in the future, many more cases of post-vaccinial myopericarditis could be seen. Practicing physicians should be aware that smallpox vaccine-associated myopericarditis is a real entity, and symptoms after vaccination should be appropriately evaluated, treated if necessary, and reported to the Vaccine Adverse Events Reporting System.

Abbreviations and Acronyms   CDC = Centers for Disease Control and Prevention   CRP = C-reactive protein   DoD = Department of Defense   ECG = electrocardiogram   ESR = erythrocyte sedimentation rate   MRI = magnetic resonance imaging   NSAID = non-steroidal anti-inflammatory drug   VIG = vaccinia immune globulin

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